| NPI | 1205976818 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NC 0010-02982) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: GA 04666) |
| Enumeration Date | 2007-02-06 |
| Last Update Date | 2017-04-27 |